Intermountain Health: Improving Clinical Outcomes and Reducing Readmissions

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# Intermountain Health: Improving Clinical Outcomes and Reducing Readmissions

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## Intermountain Healthcare – the largest nonprofit health system in the Intermountain West

- Mission: Helping people live the healthiest lives possible - Vision: Be a model health system by providing extraordinary care and superior service at an affordable cost

## Post-Discharge Calls: 2014, before the implementation of CipherOutreach

- Decentralized model, dependent on each unit managing their own follow up - Little or no coordination between those calls and outreach at the clinic level - No tracking or documentation of calls - No resources to help the patient in case of a need for service recovery - No dedicated time to help nurses focus on making meaningful calls

## Post-Discharge Calls: 2015, during the implementation of CipherOutreach

- Shift to making centralized calls using CipherOutreach, leading to improved efficiency - Shift to a centralized approach also allowed focus time to make these calls and take next steps to address concerns - Free up bedside staff for patient care - The primary goal: reduce readmission rates and ED bounce back rates across the system - Secondary goal: increase patient satisfaction - Creation of the Health Answers team

- ### Aim: - A service aimed at providing timely, free, and accurate health information and follow up to ensure seamless transitions - ### Staff: - Staff members are nurses with more than 5 years of experience from varied cultural backgrounds. Training includes phone skills, boundaries, and available resources

## Goals of the CipherOutreach implementation and Centralized Post-Discharge Calls

- Seamless transitions for patients, leading to reduced readmissions - Standardization of calls for all Intermountain Healthcare patients, regardless of how busy their unit of discharge might be - Post-discharge clinical insight, which helps to highlight problems at the unit or hospital level - Standardized documentation and issue resolution

## Patient Education is Key

- Patient education prior to discharge - Automated call - 24-48 hours - Nurse will call back based on responses

## Post-Discharge Follow-Up Focus

- Clinical vs. Patient Satisfaction - Post-discharge follow-up call focused on clinical issues - Understanding of discharge instructions - Obtaining prescriptions - Questions about medications - Follow up appointments - Barriers to follow up - Clinical specific questions - Not a patient satisfaction call

## CipherHealth Voice (now CipherOutreach) Automated Calls/Texts

- 4 attempts to reach patients over 1-2 days - Voicemail messages left it patient does not answer - Return calls trigger human follow up automatically - Negative responses trigger a live call from an Intermountain Health Answers nurse - Documentation is kept in the EMR (bidirectional interface)

## Health Answers Staff

- Experienced nurses > 5 years experience - Varied clinical backgrounds - Orientation and training include: - Phone skills - Boundaries - Resources - Clinical resources

## Health Answers Nurse Follow-up

- Timely follow up on issues (goal of less than 30 minutes per issue) - Ensures patients make seamless transition to primary care provider, reducing leakage - Help find solutions to any barriers - Escalate care as needed - Documentation in the EMR, enabling identification of common issues or trends

## Readmission Rates Improvements

- 4.9% of patients who received a phone call we readmitted within 30 days. We can see that patients who engage with outreach programs have lower readmission rates than patients who do not engage with the programs. - The average difference in readmission rates between engaged and unengaged patients is 2.6 percentage points

## Key Takeaways

- Voice, now CipherOutreach, helps identify patients requiring intervention to efficiently focus nursing time - Identification and resolution of patient concerns/issues reduces readmissions - Patient engagement post-discharge calls impacted by upstream education